Sedation May Not Always Be the Answer in Shoulder Reduction

A guest post by Dr. Andrew Kirkpatrick, an Emergency Medicine resident at the University of Texas Medical School at Houston.

What happens when you combine Ultrasound guided nerve blocks and shoulder reduction?  In the hands of experienced operators, not surprisingly, great things!

This is a randomized control trial of 41 patients out of Turkey that compared shoulder reduction utilizing procedural sedation versus an ultrasound guided suprascapular nerve block.  Using the modified Kocher method for reduction, the authors found that the nerve block leads to a statistically significant decrease in pain quantified by a Visual Analog Score.  There was also non-significant trend toward first attempt success using the Ultrasound guided nerve block, which may have been significant if the authors had bothered to calculate the appropriate sample size.  No side effects were noted in the group receiving regional anesthesia, while the sedation group predictably suffered nausea/vomiting in 15%, hypoxia in 10%, and agitation in 15%.  Time to discharge in the nerve block group was 100 minutes less than the procedural sedation group, a finding which reached statistical significance.   Lastly there was no significant difference in patient or physician satisfaction between the two groups, although trends in both cases favored the nerve block group.

Despite all of its short-comings – including small sample size, no blinding, and no clear primary outcome – the paper makes a case for using a suprascapular block to avoid the risks associated with procedural sedation for the reduction of this common dislocation.  The authors show shoulder reductions can be done in the Emergency Department without the use of procedural sedation.  True, there are some patients that cannot tolerate shoulder reduction without being fully disassociated from the event, but in the appropriately selected patient, the technique outlined in this article could decrease patient discomfort and decrease the risk to the patient undergoing shoulder reduction all without starting an IV.  In the world of emergency medicine where we are pressured to “treat and street” patients as quickly as possible while attempting to minimize risk to the patient, the ultrasound guided suprascapular nerve block seems like a great addition to the shoulder reduction armamentarium.

“A Comparison of Suprascapular Nerve Block and Procedural Sedation Analgesia in Shoulder Dislocation Reduction”
http://dx.doi.org/10.1016/j.ajem.2014.02.014